Introduction to global health strategy: theory and examples

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November 5th, 2019 Montreal, Canada

Dr. Shan Soe-Lin Dr. Robert Hecht

Topics for today What is strategy

• Ideally, it is a selection of an optimized choice based on rational assessment of evidence and weighing of trade-offs

Getting strategy right is important

• With the wrong strategic choice, businesses go bankrupt, or in public health, more people get sick or die

• With optimal strategic choices, resources and outcomes are maximized

Bad strategy vs. good strategy • Why does bad strategy happen? • How can good strategy be developed?

Real life examples of strategy development

• Advising South Africa on how to mobilize sufficient resources to achieve HIV epidemic control

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Introduction to Pharos – using evidence to drive action

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Hepatitis C (HCV) Nutrition Adolescent

Health

Country Transitions in global health

Strategy and program

development

Policy dialogue Tata Trusts

Investment case

development/ evidence-based

advocacy

Coalition Plus

What is strategy? A pop quiz

Which one of the statements below accurately and completely describes a strategy: a. A world with zero preventable maternal and child deaths

b. Invest $200M dollars over the next 5 years in cost-

effective maternal and child health interventions to avert 100,000 deaths

c. Reach 1 million women and children sustainably and equitably with lifesaving interventions

d. Achieve world peace

4

5

Strategy is: a set of guiding principles that, when communicated and adopted in the organization, generates a desired pattern of decision making. A strategy is therefore about how an organization should make decisions and allocate resources in order to accomplish key objectives. A good strategy provides a clear roadmap, consisting of a guiding plan, that defines the actions people in the business should take (and not take) and the things they should prioritize (and not prioritize) to achieve desired goals.

Michael Watkins

Strategy is just one component of an overall strategic direction

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Mission

“What” will be achieved

Roadmap

Resources, partners, timelines, sequence

to implement

Strategy

How resources should be allocated to achieve mission

Vision

Motivation

1 2

3 4 Strategic direction

Good strategy enhances competitiveness and outcomes

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Successful strategy depends upon the ability to foresee the future

consequences of present initiatives

Where do we start to build a strategy?

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Plan

Resources

Goal 1 2

3

External forces

Good strategy vs. bad strategy

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Jack Welch: “reach for what

appears to be the impossible”

1. Develop a vision to be the best or the leading or the mightiest

2. Develop a mission statement of the purpose of the organization, incorporating sustainability or other popular elements

3. List non-controversial values such as integrity, respect and excellence

4. Create some goals but call them strategies.

1. Develop a diagnosis to simplify

complexity and identify the most critical obstacles

2. Define a guiding strategic plan: develop and test scenarios, and define an overall approach to overcome the problems identified in the diagnosis and maximize outcomes

3. Identify and implement coherent actions: Coordinated steps to implement the guiding strategic plan

Bad Good

Wayne Gretzky: “skate to where the puck is going to be” [and be ready to shoot]

Three basic elements of good strategy development

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Diagnosis and assessment

• What are the future opportunities?

• What are the looming threats/risks?

• Are we ready for change?

• What are we good at? • What are our

weaknesses? • What is our risk

tolerance?

Guiding policy (strategic plan)

• Develop set of options based on diagnosis • Evaluate options based on objective criteria • Set strategic plan based on clear understanding of

opportunities, risks, tradeoffs

Coherent actions

(roadmap)

• Define what we will need to do to be ready to implement the guiding strategy

• What we will need in terms of financial, human, & technical resources

• Monitor execution and course correct

1

2

3

Failures in business come from failures to get one or more of the three elements right

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Failed to diagnose and adapt to new

digital marketplace

Pursued wrong strategy to merge with Kmart

Incoherent action: reversed decision to invest in online and

went back to retail

Similarly, failures in global health come from failures to get one or more of the three elements of good strategy right

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Fail Consequence Reason

Inadequate response to Ebola outbreak in 2014

>11,000 deaths, $53B cost to economies

Poor diagnosis of importance of cultural factors/obstacles, weak guiding principles, slow

response

America’s failure to control gun

violence

39,000 deaths per year, $229B

annual cost

Policy and political will failure, poor diagnosis

Iatrogenic HCV epidemic in Egypt

15% seropositive, $4B annual economic

cost

Wrong action to re-use needles as part of

schistosomiasis control campaign

Good strategy development in real life

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Diagnosis and analyses Strategic plan Roadmap

• Interviews with internal and external experts

• Epidemiological analyses

• Assessment of organizational capabilities

• Competitive landscape

• Development and testing of options

• Rationalization of current needs against future opportunities

• Rationalization of risks vs potential

• Development and assessment of options

• Setting of strategic direction

• Calculation of return on investment

• Determination of additional resources, including financial, human, and technical that will be needed to implement

• Timeline and sequence of implementation

• Milestones

• Framework for evaluation

Examples of strategic questions that we’ve helped our clients solve:

How to: • Justify new investments in national scale up of programs to

eliminate Hepatitis B and C in 6 countries of Asia and Africa • Help countries plan for and achieve self-sufficiency in

managing their own disease control programs after donors withdraw support

• Make the case to mobilize the resources needed to reach the World Health Assembly targets to end malnutrition

• Make the case to replenish the Global Fund’s $15B target for AIDS, TB, and Malaria

• Create forward-strategies for global health organizations to be more effective in how they allocate their funding

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Revisit the pop quiz

Which one of the statements below accurately and completely describes a strategy: a. A world with zero preventable maternal and child deaths

b. Invest $200M dollars over the next 5 years in cost-

effective maternal and child health interventions to avert 100,000 deaths

c. Reach 1 million women and children sustainably and equitably with lifesaving interventions

d. Achieve world peace

15

Strategy and Analysis in Action -- South Africa

Aids2031 and the HIV/TB Investment Case feature: • Problem Identification • Diagnosis/Analysis • Strategic Planning • Development of an Action Roadmap • Adoption and Implementation of the Roadmap • Monitoring and Evaluation • Mid-course Readjustment

Also combine data and tools (you learn at McGill) from: epidemiology, disease modeling, costing and financial analysis, political analysis and facilitation of consensus building

Overview of aids2031-South Africa

• South Africa project carried out during 2008-2010

• Linked to a global multi-country assessment of AIDS costs and financing options

• Sponsored and guided by SA National Steering Committee

•High level meetings with the SA Health Minister and the South Africa AIDS Council chaired by the Vice-President of SA

• Technical work by a joint South African and International team (CEGAA and Results for Development)

• Part of the larger aids2031 project led by Peter Piot, former Executive Director of UNAIDS

The Problem

The legacy of neglect and inaction (from a 2015 paper by the top four SA AIDS officials) (from a 2016 paper In Science on the eve of the Durban conference)

The Strategic Issues • What combination of services (prevention and

treatment) can turn the tide of the epidemic? What impact will they have?

• How much money will be needed for a strong and effective national HIV/AIDS program?

• How can available financial resources be used more efficiently?

• Who will pay for these critical HIV/AIDS activities in the future (government, private sector, donors)?

South Africa: Scenarios for the Future of AIDS

The Drivers: • Political will (higher/lower) • Pace of social norm change (fast/slow) • Outlook (emergency/long-term) • Financial capacity (higher/lower) • Implementation capacity

(constrained/unconstrained)

Scenario 1: National Strategic Plan (NSP)

Political will to achieve universal access is strong; short term outlook; few implementation constraints

Rapid scaling-up of prevention & treatment over short period, then maintenance of levels • Achieving NSP targets for 2011-12 and sustain

• Treatment – old regime at 200 CD4 threshold

• PMTCT single dose till 2009, replaced by dual therapy

• Early pediatric ART from 2009

• No Male Circumcision

Scenario 2 – Expanded NSP

AIDS seen as a long-term problem: greater focus on interventions to reduce vulnerability; slower but more sustained scale up to higher levels; no long-term funding constraints

Achievement of NSP (& extra) targets by 2021 • ART – new regime & CD4 threshold = 350 • VMMC introduced 2010, reaching 60% • Expanded workplace programmes, education, behaviour

change • Mobilization and higher coverage for Key Populations: SW, MSM • Expanded efforts for out-of-school youths • Programs to reduce violence against women

Scenario 3 – Hard Choices Resources are limited; focus on scaling up to the most

cost-effective prevention interventions; other prevention and social programs reduced; targets achieved by 2015

• Increased coverage for youth in school, condoms, male circumcision, SW & MSMs, STI treatment

• Maintaining current coverage for HCT, child grants

• Reduction below NSP targets for mass media, youth-out of-school, workplace, HBC, palliative care, food parcels, uniforms & other mitigation

• Same ART effort as under NSP

South Africa: New Adult HIV Infections, 1993-2031

0

100

200

300

400

500

600

700

800

900

Thou

sand

s

Baseline Narrow NSP Expanded NSP Hard Choices

South Africa: Adults Receiving ART, 2000-2031

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5 M

illio

ns

Baseline Narrow NSP Expanded NSP Hard Choices

South Africa: Total AIDS Funding Required, 2009-2031 (R billions)

0

5

10

15

20

25

30

35

40

45

ZAR

Bill

ions

Scenario 1 - Narrow NSP Scenario 2 - Expanded NSP Scenario 3 - Hard Choices

Summary of Main Scenario Results Status Quo/

Baseline Expanded

NSP Narrow

NSP Hard

Choices Total new infections 2009-31

(millions) 11 5 8 6

New Infections in 2031 (thousands)

500 180 360 230

Adult prevalence 2031 (percent) 17 10 15 11.5

Total AIDS deaths 2009-31 (millions)

8.1 4.4 5.9 5.8

Number of ART patients 2021 (m) 1.8 3.0 2.7 2.6

Total cost 2009-31 (R billions) NA 765 658 598

Total annual cost in 2021 (R billions)

NA 39.3 32.3 29.7

Of which ART in 2021 (percent) NA 65 70 74

SA’s epidemic is deeply entrenched: past and current dynamics make reversal extremely difficult over the next two decades

Under scenarios studied, there will still be a substantial number of new infections and prevalence will remain high for the next two decades (>10% of adults) -- in the absence of a technology breakthrough or radical behaviour change

Nevertheless, SA faces choices today that will have large positive (or negative) consequences for future costs and health outcomes

Key Findings

• If resources are limited, wise policy decisions on prevention can make an important difference: Hard Choices averts more infections & costs less than Narrow NSP

• With a more robust budget and willingness to tackle social issues and pursue a maximum prevention strategy, the rate of new infections can be curbed substantially Under Expanded NSP approach, national incidence

reduction targets can be achieved – but at a higher cost Stronger prevention now will have important knock-on

effects on lowering treatment costs in the long run

Wise Choices Matter: SA at the Crossroads

aids2031 www.resultsfordevelopment.org

Six years later…. Also from the article by the SA AODS leaders

More on the turnaround…

And from the Science paper in 2016

Financing South Africa’s HIV Response Aaron Motsoaledi

Minister of Health, South Africa

Mcebisi Hubert Jonas Deputy Minister of Finance, South Africa

Michel Sidibé Executive Director, UNAIDS

Deborah Birx Global AIDS Coordinator, United States

Mark Dybul Executive Director, The Global Fund

Moderated by Mia Malan

Director and Editor Bhekisisa: M&G Centre for Health Journalism

South Africa

With technical introduction from Robert Hecht

Results for Development Institute

Organized by National Department of Health

South Africa

In partnership with UNAIDS

Results for Development Institute

Financing South Africa’s HIV Response: Much to Celebrate, Much Left to Do

Results for Development Institute Durban, South Africa 19 July 2016 Satellite Symposium at the 21st International AIDS Conference

Robert Hecht

Most number of PLHIV Most new infections Most patients on

treatment

Why South Africa matters so much…

37 | R4D.org

6.8M HIV-infected people live in South Africa, more

than any other country

6.8

1.5

1.4

2.1

3.5

Millions

Moz/Kenya/Uganda

Nigeria

Zim/Tanzania

South Africa

India

3.4

0.9 0.9 0.9 0.8

0.0

2.5

5.0 100%

50%

0

Uga

nda

Zim

babw

e

Sout

h Af

rica

Indi

a

Keny

a

# on treatment (millions) Coverage (% of PLWH) 1/6 of all new infections

occur in South Africa…

…about 340,000 new infections per year

Data notes: all data in the left and right panels are reported for 2015 at aidsinfo.unaids.org. South Africa’s new infections in the center panel is reported in the HIV and TB Investment Case for 2013. The total number of new infections globally for that year (2.1 million) comes from aidsinfo.unaids.org.

South Africa started late but has since made dramatic progress

38 | R4D.org

The decline in new infections came later in South Africa…

...but coverage has accelerated rapidly

0

1

2

3

4

5

1990 1995 2000 2005 2010 2015

South Africa Zambia Kenya Thailand

Brazil

HIV incidence among adults 15-49 % PLHIV on treatment

3432334419

5559636548

Thai

land

Sout

h Af

rica

Zam

bia

Keny

a

+62% +84% +153%

+91% +48%

Braz

il

2015 2010

Data notes: these data come from aidsinfo.unaids.org.

Increased financing has propelled and underpinned the growth in coverage

39 | R4D.org

South Africa is the largest spender among LMICs…

…and finances the majority of HIV services with domestic resources

Brazil (2011)

1.9

South Africa (2014)

Kenya (2013)

0.7

Thailand (2013)

0.8

0.3 0.3

Zambia (2012)

Total HIV/AIDS Funding ($USD, In billions, 2014)

0

50

100

Zambia (2012)

Thailand (2013)

Kenya (2013)

South Africa (2014)

% of HIV/AIDS financing by source Domestic

Donor

Brazil (2011)

Data notes: these data come from aidsinfo.unaids.org.

The work is not done: despite successes, there are still major challenges to be addressed

40 | R4D.org

Significant financial gaps remain before

epidemic control can be achieved

Increased HIV spending risks

crowding out other health priorities

23.3 29.8 31.0 32.4 34.2

-2.8 -8.8 -8.8 -8.0 -8.1 -10

2016 2019 2018 2017 2015 Total shortfall Total resource need

6.0 8.0

10.2

2009/10 2017/18 2013/14

HIV as share of health budget (%)

Rand

(bill

ions

)

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Data notes: the top panel is a recreation of Figure 1 in the South African HIV and TB Investment Case. Data in the bottom panel come from R4D’s analysis of South Africa’s Estimates of National and Provincial Expenditure.

41 | R4D.org

Lower drug and procurement costs

Enhance workforce efficiency

Maximize program effectiveness &

efficiency

Increase sustainability

Improve coordination

Procurement and market shaping,

especially for diagnostics and

2nd/3rd line drugs

Downward task shifting

Better supervision of HCWs and other

inputs

Adherence counseling, community and family

support

Get the money to where the problem is most acute -- target

high prevalence districts

Sustain the effort financially with

stable long-term domestic sources –

integration with PHC, incorporation

in NHI

Avoid waste and unplanned gaps –

better coordination and carefully

designed transitions among Government

and Partners

How will South Africa keep funding its HIV scale-up? Strategies to get the most out of every Rand

The Strategy Cycle Continues

43 | R4D.org

When people are

determined they

can overcome anything

It always seems

impossible until

it’s done

-Nelson Mandela

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